F. Jacob Seagull

The hostile environment of the intensive care unit.

Intensive care units (ICUs) were developed for patients with special needs and include an array of technology to support medical care. However, basic lessons in ergonomics, human factors, and human performance fail to propagate in this complex medical environment. Complicated, error-prone devices are commonly used. There are too many patient data for one person to process effectively. Lighting, ambient noise, and scheduling all result in provider and patient stress. These difficult working conditions make errors more probable and are risk factors for provider burnout and negative outcomes for patients. Auditory alarms on ICU equipment, ICU syndrome, and needle sticks are discussed as examples of such problems.

An algorithm for processing vital sign monitoring data to remotely identify operating room occupancy in real-time

We developed an algorithm for processing networked vital signs (VS) to remotely identify in real-time when a patient enters and leaves a given operating room (OR). The algorithm addresses two types of mismatches between OR occupancy and VS: a patient is in the OR but no VS are available (e.g., patient is being hooked up), and no patient is in the OR but artifactual VS are present (e.g., because of staff handling of sensors). The algorithm was developed with data from 7 consecutive days (122 cases) in a 6 OR trauma center. The algorithm was then tested on data from another 7 consecutive days (98 cases), against patient in- and out-times captured by OR surveillance videos. When pulse oximetry, electrocardiogram, and temperature readings were used, OR occupancy was correctly identified 96% (95% confidence interval [CI] 95%–97%) and OR vacancy >99% of the time. Identified patient in- and out-times were accurate within 4.9 min (CI 4.2–5.7) and 2.8 min (CI 2.3–3.5), respectively, and were not different in accuracy from times reported by staff on OR records. The algorithm’s usefulness was demonstrated partly by its continued operational use. We conclude that VS can be processed to accurately report OR occupancy in real-time.

Video-based training increases sterile-technique compliance during central venous catheter insertion.

Objective:To evaluate the effect of an online training course containing video clips of central venous catheter insertions on compliance with sterile practice. Design:Prospective randomized controlled study. Setting:Admitting area of a university-based high-volume trauma center. Subjects:Surgical and emergency medicine residents rotating through the trauma services. Interventions:An online training course on recommended sterile practices during central venous catheter insertion was developed. The course contained short video clips from actual patient care demonstrating common noncompliant behaviors and breaks regarding recommended sterile practices. A 4-month study with a counterbalanced design compared residents trained by the video-based online training course (video group) with those trained with a paper version of the course (paper group). Residents who inserted central venous catheters but received neither the paper nor video training were used as a control group. Consecutive central venous catheter insertions from 12 noon to 12 midnight except Sundays were video recorded. Measurements and Main Results:Sterile-practice compliance was judged through video review by two surgeons blinded to the training status of the residents. Fifty residents inserted 73 elective central venous catheters (19, 31, and 23 by the video, paper, and control group operators, respectively) into 68 patients. Overall compliance with proper operator preparation, skin preparation, and draping was 49% (36 of 73 procedures). The training had no effect on selection of site and skin preparation agent. The video group was significantly more likely than the other two groups to fully comply with sterile practices (74% vs. 33%; odds ratio, 6.1; 95% confidence interval, 2.0–22.0). Even after we controlled for the number of years in residency training, specialty, number of central venous catheters inserted, and central venous catheter site chosen, the video group was more likely to comply with recommended sterile practices (p = .003). Conclusions:An online training course, with short video clips of actual patient care demonstrating noncompliant behaviors, improved sterile-practice compliance for central venous catheter insertion. Paper handouts with equivalent content did not improve compliance.

Adaptive leadership in trauma resuscitation teams: a grounded theory approach to video analysis

The detailed analysis of team interactions can be a source of insight into team processes and how teams interact with technology. Video recordings afford an exciting medium for such analysis. We describe a study of team leadership in the highly dynamic, high-stakes environment of trauma resuscitation. The study was conducted through video recording team activities in actual work settings and analysing the video data using a grounded theory approach. The primary research questions were: what are the functions of team leadership and how do they vary according to task situations? A corpus of 152 video segments from 18 trauma patient resuscitation cases was compiled to address these research questions. A catalog of team leadership functions was developed, along with a categorisation of the task situations in which team leadership occurred. The implications of this catalog and the mapping between leadership and task situations are discussed in relation to the findings from an interview study and a survey study on team leadership. The methodological advantages of a grounded theory approach for in-context video analysis for studying work are also discussed.

AN ANALYSIS OF PROBLEMS WITH AUDITORY ALARMS: DEFINING THE ROLES OF ALARMS IN PROCESS MONITORING TASKS

It has become a standard practice to use auditory alarm devices to enhance human monitoring performance in monitoring tasks. However, the effectiveness of such practice has been-challenged from time to time, which leads to the fundamental question of what roles alarms should and could assume. This paper reviews reported observations of interactions between human operators and alarm mechanisms in patient care, aviation, and process control. Based on the reviews, we propose that the roles of alarms in process monitoring tasks should be viewed more as a way of informing process status and less as a way of interpreting the significance of process status. The roles can best be understood in the skill-, rule-, and knowledge-based performance framework. Implications to alarm and auditory designs are discussed. Specifically, design of alarm devices should be guided by the principle of information provision regardless of whether an alarm may be true or false indication of “alarming” events.

Emergent CSCW systems: The resolution and bandwidth of workplaces

In any collaborative work settings, people naturally develop physical tools and associated work processes that support the management of the interdependencies in information, materials, and social needs. Field studies of management of operating rooms pointed out that collaborative work is supported by an infrastructure that is composed of mostly non-computerized, physical components. The supporting infrastructure is jointly maintained and exploited, with constantly evolving patterns of usage, in response to complexity of coordination needs and the uncertain environment. To represent status and plans, users seem to invent structures based both on idiosyncratic preferences and on negotiated symbols. The fluidity and ease of restructuring workplaces to support collaborative work may be explained in part by the high resolution and bandwidth of workplaces: a large number of ways in which workers could structure their work and a high capacity to convey rich information and meanings quickly to collaborators. We argue that to support health care workers, designers of computer supported cooperative work (CSCW) systems should learn how the physical and perceptual properties of workplaces are exploited, and that CSCW systems should be designed to allow maximum freedom of restructuring and reconfiguring as part of workplaces to enhance bandwidth and resolution of representation and communication.

Team Communication Patterns as Measures of Team Processes: Exploring the Effects of Task Urgency and Shared Team Experience

Inter-member team communication is a rich yet challenging data source for understanding team processes. In this paper, we present a quantitative analysis of team communication based on videotaped real-life trauma patient resuscitation. Team communication patterns were compared under varying conditions: (a) when the teams task — patient treatment — was high versus low in urgency; and (b) when team members had more or less shared experience as a team. The results provide initial support for the utility of communication analysis for the study of team performance and team leadership. Tools for assessment of team processes are a key to effective research in team performance, especially in complex, time-pressured tasks. The team communication patterns depicted the adaptive nature of team structures, especially when the teams were confronted with potentially competing goals, such as on-the-job training and treatment of trauma patients.

Negotiation and conflict in large scale collaboration: a preliminary field study

Coordinating activities in many settings can require people to manage conflict, potential and actual. Conflict arises from resource limitations, high-stakes consequences, uncertainty, goal conflict among stakeholders and hierarchical organizational structures. To understand coordination in such systems, we conducted a field study of management of surgical operating rooms. While coordinating interdependencies, such as progress monitoring, scheduling and rescheduling, and prodding, coordinators managed a set of complicated conflicts. They did so opportunistically, to resolve and to prevent conflict. Additionally, coordinators were concerned with perceived fairness. These findings indicate that, in the design of ICT to support coordination, we should examine not only the mechanical articulation of activities and efficient prioritization of resources, but also means to support companion social processes.

Online Social Networking: A Primer for Radiology

Online social networking is an immature, but rapidly evolving industry of web-based technologies that allow individuals to develop online relationships. News stories populate the headlines about various websites which can facilitate patient and doctor interaction. There remain questions about protecting patient confidentiality and defining etiquette in order to preserve the doctor/patient relationship and protect physicians. How much social networking-based communication or other forms of E-communication is effective? What are the potential benefits and pitfalls of this form of communication? Physicians are exploring how social networking might provide a forum for interacting with their patients, and advance collaborative patient care. Several organizations and institutions have set forth policies to address these questions and more. Though still in its infancy, this form of media has the power to revolutionize the way physicians interact with their patients and fellow health care workers. In the end, physicians must ask what value is added by engaging patients or other health care providers in a social networking format. Social networks may flourish in health care as a means of distributing information to patients or serve mainly as support groups among patients. Physicians must tread a narrow path to bring value to interactions in these networks while limiting their exposure to unwanted liability.

Performance of simulated laparoscopic incisional hernia repair correlates with operating room performance.

BACKGROUND the role of simulation for training in procedures such as laparoscopic incisional hernia repair (LIHR) is unknown. The purpose of this study was to determine whether performance in simulated LIHR correlates with operating room (OR) performance. METHODS subjects performed LIHR in the University of Maryland Surgical Abdominal Wall (SAW) simulator and the OR. Trained observers used a LIHR-specific global rating scale (Global Operative Assessment of Laparoscopic Skills-Incisional Hernia) to assess performance. Global Operative Assessment of Laparoscopic Skills-Incisional Hernia includes 7 domains (trocar placement, adhesiolysis, mesh sizing, mesh positioning, mesh fixation, knowledge and autonomy in instrument use, and overall competence). The correlation between simulator and OR performance was assessed using the Pearson coefficient. RESULTS fourteen surgeons from 2 surgical departments participated. Experienced surgeons (n = 9) were defined as attending surgeons and minimally invasive surgury (MIS) fellows, and novice surgeons (n = 5) were general surgery residents (postgraduate years 3-5). The correlation between performance in the OR and the simulator for the entire group was .87 (95% confidence interval, .63-.96; P < .001). CONCLUSIONS there was an excellent correlation between LIHR performance in the simulator and clinical LIHR. This suggests that performance in the SAW simulator may predict performance in the operating room.